* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Chronic Inflammatory Diseases of the Nasal Cavity and Paranasal
Survey
Document related concepts
Infection control wikipedia , lookup
Dental emergency wikipedia , lookup
Race and health wikipedia , lookup
Compartmental models in epidemiology wikipedia , lookup
Eradication of infectious diseases wikipedia , lookup
Nutrition transition wikipedia , lookup
Public health genomics wikipedia , lookup
Focal infection theory wikipedia , lookup
Diseases of poverty wikipedia , lookup
Transcript
Chronic Inflammatory Diseases Chronic Inflammatory Diseases Abstract Chapter 1 Chronic Inflammatory Diseases of the Nasal Cavity and Paranasal Sinuses Hanadi A Fatani1* 1 King Fahad Medical City, KSA Corresponding Author: Hanadi A Fatani, King Fahad Medical City, Riyadh, 59046, KSA. Email: h.fatani@ kfmc.med.sa * First Published March 10, 2016 Copyright: © 2016 Hanadi A Fatani. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source. 2 www.avidscience.com In this chapter, we examine the chronic inflammatory diseases of the nasal cavity and paranasal sinuses. First, we examine the basic characteristics of the various chronic inflammatory diseases of the nasal cavity and paranasal sinuses and chronic inflammatory diseases of the oral cavity. Further, we discuss the etiopathogenesis, diagnosis, differential diagnosis, and treatment options for the various conditions. The chapter is aimed at helping gain some insight into the current views regarding chronic inflammatory conditions of the nasal cavity and paranasal sinuses as well as the oral cavity. Chronic Inflammatory Disease of Nasal Cavity and Paranasal Sinuses Currently, the prevalence of chronic inflammatory diseases of the nasal cavity and paranasal sinuses is high. It has been reported that every 10th European has chronic inflammation of the nose and paranasal sinuses [1]. A basic understanding of the various nasal and paranasal diseases is paramount to approaching them clinically. Below is a short description of various chronic inflammatory diseases affecting the nasal cavity and the paranasal sinuses. Rhinosinusitis Sinusitis, or rhinosinusitis, is defined as the inflammation of the paranasal sinuses and nasal cavity [2]. Rhinosinusitis is the more preferred term because it encompasses the inflammation of both the nasal cavity and the inflamwww.avidscience.com 3 Chronic Inflammatory Diseases Chronic Inflammatory Diseases mation of the paranasal sinuses. Rhinosinusitis may present in the acute or chronic form, and chronic rhinosinusitis (CRS) may present with or without nasal polyps. The most common symptoms of CRS are nasal obstruction, nasal congestion, discharge, fatigue, headache, facial pressure, and dysosmia, which may also show worsening in certain seasons, such as winter [3]. CRS frequently occurs in conjunction with nasal polyps and asthma, presenting as a complex allergic entity. Thus, CRS tends to compromise the patient’s quality of life and daily functioning. The diagnostic modalities commonly used for the diagnosis of this condition are paranasal sinus computed tomography (CT), fiberoptic endoscopy, and anterior rhinoscopy [3]. The mainstay in the treatment of CRS is nasal corticosteroids, both in the presence and absence of nasal polyps [3]. Other predominant treatment options in the absence of nasal polyps are nasal wash, nasal decongestants, and systemic corticosteroids [3]. Sinonasal Inflammatory Polyp In 20–40% of the cases of CRS, nasal polyps are detected [3]. Inflammatory nasal polyps are inflammatory, polypoidalsinonasal mucous tissues that arise in response to inflammatory stimuli, such as allergy and infections, or as a component of a systemic process such as aspirin intolerance or cystic fibrosis [4]. The diagnosis of sinonasal polyps is generally established by CT or MRI. Sinonasal polyps are generally considered benign, and the condition is generally treated symptomatically, unless severe. In 4 www.avidscience.com 20-35% of the cases, surgery is required [3]. The mainstay in the medical treatment of sinonasal polyps is nasal corticosteroids [3]. The treatment of chronic rhinosinusitis with polyps is discussed in subsequent sections in detail. Paranasal Nasal Sinus Mucocele Mucoceles are defined as benign cystic lesions limited by the mucosa of the paranasal sinus itself and occurring most frequently in the paransal sinus[5]. The condition generally does not give rise to any specific group of symptoms and is most often manifested by pressure symptoms giving rise to ophthalmic or intracranial complications [6]. In fact, studies have shown that even in the presence of large lesions with significant erosion of involved tissue, the condition may remain asymptomatic [7]. A long-term study showed that a very high percentage of patients with paransal sinus mucoceles develop opthalomologic complications [8]. Surgical excision is the standard treatment for these lesions, with the endoscopic approach being the gold standard [6]. Infections Fungal sinusitis may occur as allergic fungal sinusitis, mycetoma andacute or chronic invasive fungal sinusitis [9]. www.avidscience.com 5 Chronic Inflammatory Diseases Chronic Inflammatory Diseases Allergic Fungal Sinusitis Allergic fungal sinusitis affects atopic immunocompetent individuals with fungal colonization of the sinuses. The fungus acts as an allergen triggering inflammatory reactions and thereby leading to sinus obstruction and stasis, which further promotes fungal proliferation [9]. The diagnostic criteria for this condition are detection of allergic mucin; detection of fungal specific IgE; absence of fungal invasion of the submucosa, blood, or bone; absence of immunosuppression; and radiologic evidence of opacity of the involved sinua. Typical CT findings of airfluid level seen in bacterial sinusitis are rare in fungal sinusitis, and in fact, the absence of air-fluid levels may be considered diagnostic for this condition [10,11]. Allergic fungal sinusitis has been often linked with socioeconomic conditions, and it has been observed to affect low income groups [12,13]. Mycetoma Mycetoma, sometimes referred to as “fungal ball” typically occurs in immunocompetentnonatopicindividuals[9]. In this condition, the fungus remains in the secretion, without invading the mucosa. Mycetomas are masses of fungal hyphae that elicit a low-grade chronic noninvasive inflammation of the sinuses. Most commonly, only one sinus, often the maxillary sinus, is affected [9].The condition may lead to sclerosis or calcification of 6 www.avidscience.com the sinus walls, which may be evident radiologically [9]. Clinically,the condition is mildly symptomatic or may be asymptomatic [9]. Invasive fungal sinusitis Chronic invasive fungal sinusitis extending to the orbits or the brain may occur in patients who are immunocompetent[9]. Fungal pathogens in this condition proligerate in the sinuses, eventually invading the mucosa [9]. Sinonasalmucormycosis Sinonasalmucomycosis is a rare fulminant disease affecting immunocompromised individuals. In the pediatric population, it is rare but potentially fatal [14]. Rhinosporidiosis Rhinosporidosis is an infectious disease predominantly reported from India and Sri Lanka [15] . It is caused by Rhinosporidiumseeberi. The nasal form of the disease presents with chronic mucoid discharge with painless unilateral obstruction and possible involvement of paranasal sinuses. It is also likely to affect other tissues such as conjunctiva, orapharyngeolaryngeal mucosa, and urethra [15]. www.avidscience.com 7 Chronic Inflammatory Diseases Chronic Inflammatory Diseases Bacterial Infection Rhinoscleroma Rhinoscleroma is a chronic granulomatous disease of the nasal cavity, nasopharynx, and paranasal sinuses caused by Klebsiellarhinoscleromatis. The clinical disease progresses through the catarrhal/rhinitic stage to the granulomatous/florid and sclerotic/cicatricial stages. Initial presentation involves non-specific rhinitis, followed by chronic foul purulent discharge, frequent epistaxis, nasal obstruction, crustation, and granulation, eventually resulting in permanent nasal and oral deformities [16]. Leprosy Leprosy is caused by Mycobacterium leprae and is characterized by involvement of the skin and peripheral nerves.Depression of the nasal bridge is a characteristic feature of leprosy. The nasal mucosa is the main point of entry and exit of the bacteria [17]. Tuberculosis Tuberculosis is caused by Mycobacterium tuberculosis. It is clinically characterized by prolonged cough, night sweats, and weight loss, often presenting as a prolonged low-grade fever of unknown origin. The diagnosis is confirmed by detection of acid-fast bacilli in pathological examination of sputum and radiological evidence. Vacancies are now administered in countries where the condition is 8 www.avidscience.com endemic, and the treatment involves administration of isoniazid, rifampicin, and pyrazinamide for six months [18]. Protozoal Mucocutaneousleishmaniasis Mucocutaneousleishmaniasis is caused by Leishmaniabrasiliensis. Almost 40% of patients develop mucocutaneous involvement, with the typical early symptoms being nasal obstruction associated with a nodule or polyp at the inferior turbinate. The disease eventually progresses to destroy the nasal septum and destroy the nose and mouth if not controlled [19]. Viral Infection Herpes Herpes simplex is caused by herpes simplex virus (HSV) type I or II and manifests as painful blisters or ulcers around the nose and mouth [20]. Oral lesions are generally caused by HSV type I. Tingling, itching, or burning may be experienced before the appearance of the blisters [20]. CMV Cytomegalovirus infection (CMV) is a self-limiting disease caused by human herpes simplex virus 5. CMV is clinically similar to CMV and characterized by fever, gen- www.avidscience.com 9 Chronic Inflammatory Diseases Chronic Inflammatory Diseases eralized lymphadenopathy and hepatosplenomegaly [21]. Infectious mononucleosis Infectious mononucleosis is caused by Epstein-Barr virus and manifests as fever, pharyngitis, and lymphadenopathy. The condition is self-limiting and generally occurs in immunocompetent individuals [22]. Chronic Inflammatory Diseases of the Oral Cavity Drug-Related Gingival Hyperplasia Some anticonvulsants such as phenytoins, calciumchannel blockers such as nifedipine, and immunosuppresants such as cyclosporine cause clinically and histologically similar gingival enlargement in susceptible patients [26]. Gingival Fibromatosis Periodontal Disease Periodontal diseases are diseases affecting the gingiva and alveolar bone. It is a growing public health concern, with many risk factors, including poor oral hygiene; tobacco use or smoking; psychological factors such as stress; related systemic conditions such as diabetes mellitus, obesity, and cardiovascular disease; use of drugs influencing salivary flow; being the main risk factors for periodontal diseases [23]. Gingivits Chronic gingivitis is the chronic inflammation of the gingiva. Plasma Cell Gingivitis Plasma cell gingivitis is a rare condition that is characterized by the diffuse and extensive infiltration of plasma 10 cells into the sub-epithelial tissue [24]. It may be caused by allergens, be neoplastic in origin, or idiopathic [25] and is manifested by hypersensitivity [24]. www.avidscience.com Gingival fibramatosis is defined as the overgrowth of the collagenous portion of the non-epithelial gingival tissue [27]. It may be hereditary, idiopathic, or drug-induced. Bacterial Infection Streptococcal tonsillitis with pharyngitis Streptococcal tonsillitis generally presents with highgrade fever (above 100°F), pharyngitis, tonsillar exudates, and cervical lymphadenopathy. The diagnostic standard is detection of the bacteria in throat culture. Tuberculosis Although TB usually affects the lungs, it can also have extra-pulmonary manifestations. The oral lesions are typically asymptomatic appearing in the oral buccal mucosa and may be either primary or secondary [28]. They generwww.avidscience.com 11 Chronic Inflammatory Diseases Chronic Inflammatory Diseases ally affect the oral mucosa, especially the tongue, or the gingival tissue and appear as chronic ulcers, nodules, or granulomas. Diagnostic confirmation by pathology and proper treatment are necessary. Leprosy Oral manifestations of leprosy range from non-specific lesions such as enanthema of palate to specific lesions such as nodules or ulcers that may show positivity for the pathogenic bacteria (Mycobacterium leparae).The lesions are insidious and may be aymptomatic [29]. Actinomycosis Actinomycoses is a rare chronic bacterial infection caused by anaerobic bacteria of Actinomyces spp., which colonize in the mouth and the digestive and genital tracts. Typical microscopic findings include necrosis with yellowish sulfur granules and filamentous gram–positive fungal pathogens [30]. Apart from the common respiratory tract presentation, the disease can also manifest in a cervicofacial form, which is acquired via a mucosal breach and presents as an slow-growing indurated mass with subsequent abscess formation and appearance of yellowish exudates containing sulfur granules. Cat scratch disease Cat scratch disease is a bacterial zoonotic disease generally presented as lympadenopathynear the site of cat scratch or bite, fever, and fatigue. It is caused by Bartonellahenselae. 12 www.avidscience.com Fungal and Protozoal Disease Candidiasis Oropharyngeal candidiasis is caused by Candidia spp., most often Candidiaalbicans. The infection is generally regarded as an opportunistic infection, mainly affecting immunocompromised individuals. Clinically, the lesions are characterized by pseudomembranous, erythematous, or hyperplastic appearance. Chronic atrophic candiasis is a form of the disase that is associated with denture use. [31]. Zygomycosis Zygomycosis or mucormycosis is a fungal disease caused by fungi of the order Mucorales. The disease is characterized by a high mortality rate and genrally affects immunocompromised lesions. Oral lesions such as ulcers serve as point of entry for the organism, which evades the hard palate, maxillary bone,paranasal sinuses, and the orbital and intracranial cavities [32]. Aspergillosis Aspergillosis of the sinonasal tract is caused by Aspergillus sp. Predisposing factors are immunosuppression and obstructive nasal lesions [33]. Viral Disease Herpes simplex virus Oral lesions of herpes simplex are generally caused by HSV I. The lesions typically occur as localized clusters of www.avidscience.com 13 Chronic Inflammatory Diseases Chronic Inflammatory Diseases painful blisters or ulcers occurring around the mouth. Cytomegalovirus infection Cytomegalovirus infection is caused by CMV.Although similar in clinical presentation to infectious mononucleosis, CMV infection rarely includes pharyngitis. Clinical Feature Site Etiology Lam et al discussed the current understanding on the etiopathogenesis of CRS intheir review [34]. These hypotheses suggest the notion that CRS occurs due to an interplay between individual host characteristics and exogenous factors. They grouped the current concepts on CRS etiology and pathogenesis into the following categories: (1) the “fungal hypothesis,” (2) the “superantigen hypothesis,” (3) the “biofilm hypothesis,” and (4) the “microbiome hypothesis,” all of which emphasize key environmental factors, and (5) the “eicosanoid hypothesis” and (6) the “immune barrier hypothesis,” which describe specific host factors [34]. Some of the common bacterial infections are caused by the pathogenic transformation of bacteria that are normally present in the nasal and oral mucosa, e.g., actinomycosis and candidiasis.Certain viral infections such as cytomegalovirus occur in those immunocompromised. 14 www.avidscience.com Risk With regard to CRS and allergic fungal rhinosinustis, a recent cohort study of patients from North Carolina showed that patients with CRS have higher income, more access to primary care, and lower markers of disease severity than those with allergic fungal rhinosinusitis [13]. The role of socioeconomic factors in the occurrence of allergic fungal rhinosinusitis has also been reported by others [12]. Miller et al [35] have shown that markers of disease severity (namely, bone erosion and orbitocranial involvement) in AFRS were associated with low income, rural residence, poor housing quality, and less health care access.Several diseases of the oral cavity such as tuberculosis also spread because of overcrowding, poor oral hygiene, and denture use. Gender and Age Diseases such as infectious mononucleosis are common in adolescents and young adults, while CSR is mostly seen in middle aged adults. No particular gender predilection is seen for these diseases. Histology The main histological characteristics of chronic rhinosinusitis with nasal polyps are proliferation of pseudostratified respiratory epithelium, thickening of the basement membrane, focal fibrosis and eosinophilic and lymphocytic infiltration of the lamina propria [36].Alwww.avidscience.com 15 Chronic Inflammatory Diseases Chronic Inflammatory Diseases though the exact etiopathogenesis of nasal polyps remains elusive, currently two hypotheses are predominantly implcated: “hypothesis of staphylococcal superantigens” and “hypothesis of immune barrier dysfunction” [36]. Further, more recent findings indicate that HMG B1 may play a crucial role in the pathogenesis of CRS with nasal polyps [37]. Differential Diagnosis The diagnosis of CRS on the basis of the symptom presentation alone is difficult. Bhattacharya [38] conducted a study on the correlation between reported symptoms and radiographic evidence of chronic sinusitis and found that there is little correlation between the two, thereby suggesting that the diagnosis of CRS based on symptom criteria alone is difficult because most symptoms (other than dysosmia) do not distinguish between radiographically normal and diseased patients. The presence of a polyp and dysosmia were found to be the only criteria that successfully distinguished between radiographically diseased and normal individuals. Similarly, Lange et al investigated the value of questionnaire-based and clinical-based diagnosis and evaluation of CRS and found only moderate agreement self-reported questioannaire scores and clinical-based assessment.As stated above, the absence of air-fluid levels may be suggestive of the diagnosis of allergic fungal sinusitis. [10,11]. In cases of allergic fungal sinusitis, CT scans 16 www.avidscience.com may show opacity in the affected sinus, and the absence of the typical air-fluid levels in the case of acute bacterial sinusitis. In cases of mycetoma, sclerosis or calcification of the sinus wall may be seen in later stages [9]. Most diseases of the oral cavity, such as herpes, present with typical lesions. Isolation of the pathogenic bacteria, such as acid-fast bacilli, from oral mucosa or secretions is generally necessary to establish the diagnosis. Others such as tuberculosis, which may present with non-specific lesions need to be investigated by histopathological studies to confirm the diagnosis. Diseases with systemic manifestations such as leprosy may be distinguished by their typical clinical presentation and diagnostic features. Treatment The mainstay in the treatment of CRS is nasal corticosteroids, nasal washes, and decongestants [3]. About 20–35% of the patients require surgery [3]. For CRS with nasal polps, evidence for short-term use of systemic corticosteroids has been shown to be favorable, but not as much in CRS without nasal polyps [39]. Topical corticosteroids improve symptom scores in both CRS subgroups. The role of microbes in CRS is still controversial. Culturedirected antibiotics are recommended for CRSsNP with exacerbation. Long-term use of low dosage antibiotics is recommended for CRSsNP for their anti-inflammatory effects [39]. www.avidscience.com 17 Chronic Inflammatory Diseases Chronic Inflammatory Diseases With respect to allergic fungal rhinosinusitis, the treatmentmainly relies upon the surgical removal of fungal hyphae in eosinophilicmucin [40]. A recent review [40] suggested that although several uncontrolled studies support the beneficial effect of antifungal agents in AFRS, but randomized trials of topical and systemic antifungal therapies have not shown beneficial results in CRS. Antifungal treatment within the sinonasal cavities does not appear to be an effective approach for most chronic sinusitis, and antifungal therapy for AFRS is unproven [40]. Recent studies [41] have shown that refractory CRS that significantly affect the patient’s quality of life does not respond to continued medical therapy. A recent meta-analysis showed that current trend is to recommend endoscopic sinus surgery after failure of 8-week course of topical intranasal corticosteroids and 3-week course of oral antibiotics, and in some cases the use of systemic corticosteroids [42]. On the other hand, studies have also indicated that no clear evidence is available to prove the superiority of surgical treatment over medical treatment for chronic sinusitis with polyp, in terms of symptom scores or quality of life scores; therefore, further investigations are necessary to determine the most suitable forms of treatment for this condition [43]. Watt and Petersen [23] highlighted the importance of shifting from individual focus to developing effective public health measures to combat periodontal disease. Infective diseases such as tuberculosis and leprosy need to be 18 www.avidscience.com tackled by widespread, effective public health measures, particular in countries where the conditions are endemic. Further, awareness regarding the maintenance of oral hygiene and the effects of tobacco use, which are causes for several types of oral lesions, need to be generated in the public. This will help reduce the incidence of diseases such as chronic gingivitis. Figure 1: Paranasal sinuses (From Mosby’s Medical Diction- ary, 8th edition. S.v. “Paranasal sinus diseases.” Retrieved on January 09, 2016 from http://medical-dictionary.thefreedictionary.com/ Paranasal+sinus+diseases) www.avidscience.com 19 Chronic Inflammatory Diseases Chronic Inflammatory Diseases Figure 2 and Figure 3: Treatment for chronic rhinosinusitis. (From Piromchai P, Kasemsiri P, Laohasiriwong S, Thanavirata- nanich S. Chronic rhinosinusitis and emerging treatment options. Int J Gen Med. 2013 Jun 7;6: 453-464. doi: 10.2147/IJGM.S29977. Print 2013.) 20 www.avidscience.com Figure 4: Chronic gingivitis. (a) Histopathologic characteristics in a biopsy section of the epithelial and connective tissues of mild non-specific chronic gingivitis: Epithewww.avidscience.com 21 Chronic Inflammatory Diseases Chronic Inflammatory Diseases lial hyperplasia, mild inflammatory lymphocyte infiltrate. HE. Original magnification ×100. (b) Histopathologic characteristics in a biopsy section of the epithelial and connective tissues of moderate non-specific chronic gingivitis: Proliferation of epithelial crests, moderate inflammatory lymphocyte infiltrate, congestion. HE. Original magnification ×100. (c) Histopathologic characteristics in a biopsy section of the epithelial and connective tissues of severe non-specific chronic gingivitis: Epithelial atrophy, spongiosis, severelymphoplasmocytic infiltration. HE. Original magnification ×200. (From Myriam A. Koss, Cecilia E. Castro,1 Silvia Carino,2 and Maria E. LópezHistopathologic and histomorphometric studies and determination of IL-8 in patients with periodontal disease J Indian SocPeriodontol. 2014 Mar-Apr; 18(2): 145–149.) References 1. Riechelmann H; Europäischen Akademie für Allergie und Klinische Immunologie (EAACI) under European Rhinologic Society (ERS). [Chronic Rhinosinusitis - EPOS 2012 Part I]. Laryngorhinootologie. 2013; 92: 193-201. 2. Gorbach SL, Falagas M. The 5-Minute Infectious Diseases Consult. Boston: Wolters Kluwer. 2001. 3. Passali D, Cingi C, Cambi J, Passali F, Muluk NB. A survey on chronic rhinosinusitis: opinions from experts of 50 countries. Eur Arch Otorhinolaryngol. 2016;. 4. Robinson, Robert. Nose, Paranasal Sinuses, and Nasopharynx. In: Head and Neck Pathology: Atlas for Histologic and Cytologic Diagnosis. Philadelphia: Lippincott Williams & Wilkins. 2012; 142. 5. Stamm AC, Draf W, editors. Micro-endoscopic sinus surgery in children. In: Micro-endoscopic Surgery of the Paranasal Sinuses and the Skull Base. Berlin: Springer. 2012; 363. Figure 5: Allergic fungal rhinosinusitis: CT image demonstrating heterogenous signal intensity that is characteristic of AFS. (From Daniel Glass, MD* and Ronald G. Amedee, MD Allergic Fungal Rhinosinusitis: A ReviewOchsner J. 2011 Fall; 11(3): 271–275.PMCID: PMC3179194). 22 www.avidscience.com 6. Hssaine K, Belhoucha B, Rochdi Y, Nouri H, Aderdour L, et al. Paranasal sinus mucoceles: About 32 cases. Rev Stomatol Chir Maxillofac Chir Orale. 2015; 00188-00183. 7. Scangas GA, Gudis DA, Kennedy DW. The natural history and clinical characteristics of paranasal www.avidscience.com 23 Chronic Inflammatory Diseases Chronic Inflammatory Diseases sinus mucoceles: a clinical review. Int Forum Allergy Rhinol. 2013; 3: 712-717. tis. Otolaryngol Head Neck Surg. 2015; 153: 137143. 8. Lee TJ, Li SP, Fu CH, Huang CC, Chang PH. Extensive paranasal sinus mucoceles: a 15-year review of 82 cases. Am J Otolaryngol. 2009; 30: 234238. 14.Rassi SJ, Melkane AE, Rizk HG, Dahoui HA. Sinonasal mucormycosis in immunocompromised pediatric patients. J Pediatr Hematol Oncol. 2009; 31: 907-910. 9. Grammer, Leslie, Paul Greenberger. Radiologic Evaluation of Allergic and Related Diseases. In: Patterson’s Allergic Diseases. 7th edn. Baltimore: Wolters Kluwer Health/Lippincott Williams & Wilkins. 2009; 165. 15.Berger, Stephen A. Rhinosporidosis. In: Infectious Diseases of the World. Los Angeles.: Gideon Informatics. 2015; 1028. 10.Meltzer EO, Hamilos DL, Hadley JA, Lanza DC, Marple BF. Rhinosinusitis: developing guidance for clinical trials. J Allergy Clin Immunol. 2006; 118: S17-61. 11.Mukherji SK, Figueroa RE, Ginsberg LE, Zeifer BA, Marple BF. Allergic fungal sinusitis: CT findings. Radiology. 1998; 207: 417-422. 12.Wise SK, Ghegan MD, Gorham E, Schlosser RJ. Socioeconomic factors in the diagnosis of allergic fungal rhinosinusitis. Otolaryngol Head Neck Surg. 2008; 138: 38-42. 13.Lu-Myers Y, Deal AM, Miller JD, Thorp BD, Sreenath SB. Comparison of Socioeconomic and Demographic Factors in Patients with Chronic Rhinosinusitis and Allergic Fungal Rhinosinusi24 www.avidscience.com 16.Ahmed AR, El-Badawy ZH, Mohamed IR, Abdelhameed WA. Rhinoscleroma: a detailed histopathological diagnostic insight. Int J Clin Exp Pathol. 2015; 8: 8438-8445. 17.Lastória JC, Abreu MA. Leprosy: review of the epidemiological, clinical, and etiopathogenic aspects - part 1. An Bras Dermatol. 2014; 89: 205218. 18.Berger, Stephen A. Tuberculosis. In: Infectious Diseases of the World. Los Angeles.: Gideon Informatics, 2015; 1258. 19.Berger, Stephen A. Leishmaniasis mucocutaneous. In: Infectious Diseases of the World. Los Angeles: Gideon Informatics, 2015; 634. 20.Herpes Simplex Virus. World Health Organization. 2016. http://www.who.int/mediacentre/ factsheets/fs400/en/. www.avidscience.com 25 Chronic Inflammatory Diseases Chronic Inflammatory Diseases 21.Berger, Stephen A. Cytomegalovirus infection. In: Infectious Diseases of the World. Los Angeles: Gideon Informatics. 2015; 265. 22.Berger, Stephen A. Infectious mononucleosis. In: Infectious Diseases of the World. Los Angeles: Gideon Informatics. 2015; 537. 30.Valour F, Sénéchal A, Dupieux C, Karsenty J, Lustig S. Actinomycosis: etiology, clinical features, diagnosis, treatment, and management. Infect Drug Resist. 2014; 7: 183-197. 23.Watt RG, Petersen PE. Periodontal health through public health--the case for oral health promotion. Periodontol 2000. 2012; 60: 147-155. 31.Patil S, Rao RS, Majumdar B, Anil S. Clinical Appearance of Oral Candida Infection and Therapeutic Strategies. Front Microbiol. 2015; 6: 1391. 24.Macleod RI, Ellis JE. Plasma cell gingivitis related to the use of herbal toothpaste. Br Dent J. 1989; 166: 375-376. 32.Reddy SG, Kumar KK, Sekhar CP, Reddy RB. Oral mucormycosis: Need for early diagnosis. J NTR Univ Health Sci. 2014; 3: 145-147 25.Joshi C, Shukla P. Plasma cell gingivitis. J Indian Soc Periodontol. 2015; 19: 221-223. 33.Rao JJ, Vinaya Kumar EC, Chowdary VS, Kumar N, Reddy KJ. Invasive Sino Nasal Aspergillosis diagnostic criteria. Indian J Otolaryngol Head Neck Surg. 2001; 53: 295-298. 26.Dongari A, McDonnell HT, Langlais RP. Druginduced gingival overgrowth. Oral Surg Oral Med Oral Pathol. 1993; 76: 543-548. 27.Wenig, Bruce M. Non-neoplastic Lesions of the Oral Cavity. In: Atlas of Head and Neck Pathology. 2nd edn. Philadelphia: Saunders/Elsevier. 2008. 28.Kapoor S, Gandhi S, Gandhi N, Singh I. Oral manifestations of tuberculosis. CHRISMED J Health Res. 2014; 1: 11-14. 29.Pallagatti S, Sheikh S, Kaur A, Aggarwal A, Singh 26 R. Oral cavity and leprosy. Indian Dermatol Online J. 2012; 3: 101-104. www.avidscience.com 34.Lam K, Schleimer R, Kern RC. The Etiology and Pathogenesis of Chronic Rhinosinusitis: a Review of Current Hypotheses. Curr Allergy Asthma Rep. 2015; 15: 41. 35.Miller JD, Deal AM, McKinney KA, McClurg SW, Rodriguez KD. Markers of disease severity and socioeconomic factors in allergic fungal rhinosinusitis. Int Forum Allergy Rhinol. 2014; 4: 272279. 36.Perić A, Vojvodić D. [Inflammatory mechanisms www.avidscience.com 27 Chronic Inflammatory Diseases Chronic Inflammatory Diseases in nasal polyposis]. Srp Arh Celok Lek. 2014; 142: 740-746. 37.Bellussi LM, Chen L, Chen D, Passali FM, Passali D. The role of High Mobility Group Box 1 chromosomal protein in the pathogenesis of chronic sinusitis and nasal polyposis. Acta Otorhinolaryngol Ital. 2012; 32: 386-392. Rhinol. 2015; 22. 43.Rimmer J, Fokkens W, Chong LY, Hopkins C. Surgical versus medical interventions for chronic rhinosinusitis with nasal polyps. Cochrane Database Syst Rev. 2014; 12: CD006991. 38.Bhattacharyya N. Clinical and symptom criteria for the accurate diagnosis of chronic rhinosinusitis. Laryngoscope. 2006; 116: 1-22. 39.Piromchai P, Kasemsiri P, Laohasiriwong S, Thanaviratananich S. Chronic rhinosinusitis and emerging treatment options. Int J Gen Med. 2013; 6: 453-464. 40.Ryan MW, Clark CM. Allergic Fungal Rhinosinusitis and the Unified Airway: the Role of Antifungal Therapy in AFRS. Curr Allergy Asthma Rep. 2015; 15: 75. 41.Smith KA, Rudmik L. Impact of continued medical therapy in patients with refractory chronic rhinosinusitis. Int Forum Allergy Rhinol. 2014; 4: 34-38. 42.Dautremont JF, Rudmik L. When are we operating for chronic rhinosinusitis? A systematic review of maximal medical therapy protocols prior to endoscopic sinus surgery. Int Forum Allergy 28 www.avidscience.com www.avidscience.com 29